More Information on HMO Health Insurance Plans
Part 2, Chapter 7: Managed-Care Plans Page 3
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However, in order to obtain full benefits, HMO participants are generally expected to make use of network providers. Participants may also be required to pay a small fee for each visit to a doctor. In addition, coverage for a consultation with a specialist or for medical tests may be available only with the agreement of the primary care physician.
The primary care physician is often referred to as the gatekeeper, since that physician controls access to medical specialists and to other medical services. In practical terms, that means that in order to consult a neurologist, a psychiatrist, an orthopedic surgeon, a rheumatologist, or other specialist, or in order to arrange for a CAT scan (computerized axial tomography), an MRI (magnetic resonance imaging), or another type of expensive medical test, a patient must generally first obtain the approval of the primary care physician.
If an HMO has a POS (Point-of-Service) Option, participants may be able to occasionally consult out-of-network providers and still receive partial reimbursement. Check with your HMO to determine the specific rules for coverage under the P0S option. If a P0S option is not available through a particular HMO, patients can always go outside the system to arrange for medical tests or to obtain treatment for a disease or condition. However, they must generally do so at their own expense, unless the HMO grants approval to consult a provider who is not part of the plan network.
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